Request a referral - Application for assistance and financial statement

This is available to the families of doctors who have worked in the Mersey Deanery at some time in their career.

1. Details of medical practitioner who is the applicant or spouse or parent of the applicant

Applicant is a medical practitioner

YesNo

Details of Dependants

Names of children and other household members. Status sholud be : school pupil / student / employed / ill / disabled etc.

Dependant 1 name

2. Medical qualifications.

University

GMC Registration Number

Currently registered

Type of registration

FullProvisionalLimited

3. Further details

(a) Have you made any application to the Royal Medical Benevolent Fund?

YesNo

(b) Have you made application to any other charity / organisation for assistance?

YesNo

May we confer (in the strictest confidence) with any other organisation we consider might be able to help?

Yes

4. Financial details

Monthly Income
(If a monthly amount cannot be given, provide quarterly (Q) or annual (A) figures in the fields. Amounts given are to be after payment of income tax, if any, has been deducted).

Salary